'It's About Living Better': Repositioning Palliative Care in Hematologic Cancer

Theodore Bosworth


February 24, 2016

The role of palliative care is widely misperceived as a strategy reserved for patients with limited options in advanced stages of disease. This misperception has been standing in the way of broader application of treatments that can improve quality of life (QOL) of patients with serious disease even when the prognosis is good, according to experts at a symposium devoted to this topic during the 2015 annual meeting of the American Society of Hematology.

"Palliative care has moved further upstream in the 21st century. It's really about supporting people through a serious illness. It is more about living better rather than about the issues that arise only at the end of life," reported Thomas W. LeBlanc, MD, Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina.

It is more about living better rather than about the issues that arise only at the end of life

Several subgroups of patients with hematologic cancers, including many of those scheduled for hematopoietic stem cell transplant (HSCT), are reasonable candidates for palliative care. However, Dr LeBlanc cited data indicating that palliative care is less likely to be offered to patients with hematologic cancer than those with solid tumors, even at the end of life.[1]

Palliative care, which is directed at symptom control and the stress imposed by symptoms, is already fundamental to hospice and end-of-life management, but it is a strategy that can be initiated at any stage of disease, including at the time of diagnosis. Although palliative care is not a treatment for the disease, it can be delivered alongside forms of treatment with curative intent in order to improve QOL.

The misperception that palliative care is reserved for the management of late-stage or terminal disease persists even though an array of organizations, including the American Society of Clinical Oncology (ASCO) and the World Health Organization, clearly define a much broader role for it. Both have issued statements emphasizing that palliative care can be helpful in the management of pain and the physical and psychosocial complications of serious diseases without regard to prognosis. In cancer specifically, Dr LeBlanc pointed out that ASCO policy statements advocate palliative care for any patient with a high symptom burden.

A misperception among clinicians about the role of palliative care may pose the greatest challenge to broader application.

A misperception among clinicians about the role of palliative care may pose the greatest challenge to broader application. Dr LeBlanc noted that a reluctance to refer patients to palliative care sometimes arises from the clinician's concern that this sends a message to patients that they have a poor prognosis. Dr LeBlanc then countered that patients do not necessarily apply the same negative connotations to this term, with which they are often unfamiliar. Moreover, the documented benefits of palliative care make it an appropriate strategy irrespective of this prejudice.

In clinical trials, early palliative care has been associated with various benefits, including an improved median overall survival (OS). In a randomized trial conducted in patients with newly diagnosed metastatic non-small-cell lung cancer, the significant improvement in QOL (P=.03) for palliative relative to standard care was accompanied by both a reduction in depressive symptoms (P=.01) and a significantly extended OS (11.6 vs 8.9 months; P=.02).[2] This trial, like several others documenting benefit from palliative care,[3,4,5] was confined to solid tumors, but Dr LeBlanc pointed out that many hematologic cancers impose a similar symptom burden with the same potential for large improvements in QOL when the symptoms are modified.

This potential is already being explored in patients undergoing HSCT for hematologic cancer. According to Eric Roeland, MD, of Moores Cancer Center at University of California, San Diego (UCSD), HSCT is often a challenging, stressful ordeal for patients, with sequelae that can persist even after a successful engraftment. For example, graft-vs-host disease, a common complication, can cause prolonged impairments in QOL regardless of whether cancer is detectable. Moores Cancer Center has been at the forefront of transitioning palliative care from an "over-the-cliff" approach used only in cases of HSCT failure to an upfront strategy that is used regularly regardless of prognosis.

The new model is simultaneous integration—making palliative care routine, not an exception

"The new model is simultaneous integration—making palliative care routine, not an exception," Dr Roeland reported. At UCSD, where palliative care has been integrated with HSCT for approximately a decade, board-certified palliative care specialists lead a multidisciplinary team. Many of the other members of the team, which includes nurses, social workers, and pharmacists, have received formal training in palliative care, according to Dr Roeland. Again, goals include improvement in QOL through symptom management and care planning; however, Dr Roeland acknowledged, "We still have a long way to go, especially on integrating palliative care into the outpatient side."

Palliative care specialists can help patients and physicians communicate. Often, new information about prognosis or treatment creates an emotionally charged atmosphere that makes this information difficult to digest. Patients and family members frequently benefit from a discussion of options with a palliative care team that is independent of those administering the care, according to Dr Roeland. Conversely, there are often situations when patients do not fully disclose the extent of pain or other symptoms to treating physicians, out of concern that this may lead to less aggressive treatment. Again, palliative care specialists can be facilitators of this type of information exchange.

Because it is often difficult to predict the course of hematologic cancer, including response to HSCT, Dr Roeland maintained that "we believe that the best opportunity to integrate palliative care for many patients may be at the time of diagnosis."

A study to evaluate the impact of palliative care on HSCT is now being led by Areej El-Jawahri, MD, from Massachusetts General Hospital Cancer Center in Boston. Endpoints in this study, which is designed to evaluate the impact of early integration of palliative care in HSCT, include measures of QOL, mood, nonrelapse mortality, and OS at 1 year. A positive result is likely to accelerate the use of palliative care in HSCT as well as promote its application in other areas of hematologic cancer treatment with a high symptom burden.

As a specialty, palliative care has grown exponentially. According to Dr LeBlanc, more than 90% of hospitals with 300 beds or more now have palliative care programs—a substantial increase relative to a decade ago. In the United States, there are approximately 7000 board-certified palliative care specialists who must now complete fellowship training in order to sit for the Hospice and Palliative Medicine Boards. More than 100 training programs have been established. However, the importance of this treatment approach remains underappreciated, according to Dr LeBlanc.

"Palliative care provides a favorable impact on the things we can agree on that really matter, including QOL, symptom severity, and outcome. We see these types of improvements relatively consistently across studies," Dr LeBlanc said. Although hospice care "is now really a small part of palliative medicine," it is important to communicate to patients that palliative care is designed to help patients live better, said Dr LeBlanc.

"When you spin it that way, patients will be very open to it," Dr LeBlanc said.

Disclosures: Dr LeBlanc reported financial relationships with Boehringer-Ingelheim, Epi-Q, Flatiron, and Helsinn Therapeutics.

Dr Roeland reported financial relationships with Cellceutix, Eisai, Helsinn, Inform Genomics, and Teva.


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